Atypical presentation of herpes zoster: Zoster sine herpete

Abstract

Herpes zoster dermatitis is a vesicular eruption occurring in a dermatomal distribution
secondary to the reactivation of varicella zoster virus. Prodromal symptoms of paresthesia,
hyperesthesia, and pruritus normally occur in the regions where the vesicular eruptions develop,
typically preceding the cutaneous eruptions. However, this reactivation can present atypically
with few to no cutaneous lesions, referred to as zoster sine herpete.

This case report describes a middle aged, immunocompetent man with zoster sine herpete,
who initially presented with a four-day history of severe migratory prodromal pain and hyperesthesia situated in dermatomal distributions. Physical exam revealed two groups of 2–4 mm
erythematous papules of the skin on the left posterior neck and left flank. However, the patient’s
sensory symptoms did not align with the dermatomes of his asymptomatic non-vesicular skin
lesions.

Herpes zoster dermatitis may present atypically, with prodromal neuralgia occurring in
differing dermatomes from where cutaneous findings occur, if any eruption occurs at all. In
such cases, it is important to rely on the patient’s history, timeline, and description of symptoms
in conjunction with a thorough skin examination to diagnose zoster sine herpete. In addition, if
no skin findings are present, serologic testing can be used to make the diagnosis.
Keywords: Herpes zoster, zoster sine herpete, varicella zoster virus, herpetic neuralgia